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Research ArticlePolicy Forum

Understanding, Detecting, and Managing the Risk of Posttraumatic Osteoarthritis Following Anterior Cruciate Ligament Reconstruction in the Military

Brian Pietrosimone
North Carolina Medical Journal September 2017, 78 (5) 327-328; DOI: https://doi.org/10.18043/ncm.78.5.327
Brian Pietrosimone
associate professor, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Anterior cruciate ligament (ACL) injuries occur approximately 4 to 5 times more frequently among active duty military personnel [1] compared to the general public [2, 3]. While 90% of individuals return to active duty following ACL reconstruction (ACLR) [4], approximately one-third of all individuals will develop posttraumatic osteoarthritis (PTOA) within the first decade following ACLR, and approximately 50% of individuals will develop PTOA within 2 decades following ACLR [5]. Osteoarthritis is the second leading cause of military discharge during armed conflict [6], and approximately 35% of all knee osteoarthritis cases in the military occur following a joint injury [7]. PTOA was the cause of end-stage joint disease in 75% of knees in a cohort (N = 64) of young military personnel (≤50 years old) undergoing total knee arthroplasty [8]. ACL injuries have devastating long-term effects on quality of life, which negatively impact the career longevity for many military personnel. Unfortunately, there are no current disease-modifying interventions for PTOA; thereby, prevention of PTOA onset following joint injury is critical for maintaining long-term health. Therefore, in addition to returning patients to unrestricted physical activity, clinicians should focus on early detection of PTOA development and management of PTOA risk in patients following ACLR.

As early as 4 years following an ACLR, individuals with a unilateral ACLR demonstrate greater radiographic tibiofemoral joint space narrowing on the ACLR limb compared to the contralateral limb [9]. However, deleterious changes in joint tissue metabolism occur within days to weeks of ACL injury and ACLR [10]. Relying on traditional radiographic evaluation of structural joint changes may not detect the early tissue changes that occur at a molecular level, which may lead to PTOA onset. Decreased proteoglycan density of the tibiofemoral articular cartilage has been demonstrated within the first 24 months following ACLR using novel T1ρ magnetic resonance imaging [11-13]. Patient-reported function can be used to detect individuals who demonstrate poor outcomes following ACLR.

Approximately 43% and 39% of ACLR patients report unacceptable outcomes using cutoff values derived from the Knee Injury and Osteoarthritis Outcomes Score [14] at 2 (N = 1530) and 6-year (N = 1506) follow-up exams, respectively [15]. Functional screening of slow habitual walking speed has been used to predict those who will develop idiopathic osteoarthritis [16]. In a cohort of older individuals at risk for developing osteoarthritis, a 0.1 m/s decrease in habitual walking speed over a 12-month period was associated with an 8% increased risk of developing radiographic osteoarthritis in the subsequent 24-months [17]. In younger individuals with an ACLR, slower walking speeds associate with greater concentrations of serum biomarkers of collagen breakdown [18]. Therefore, future efforts to detect early PTOA may need to focus on early compositional tissue alterations, as well as clinical changes in patient-reported function and activities of daily living, such as habitual walking speed.

Management of PTOA risk should begin prior to the development of the earliest signs or symptoms in order to maximize long-term joint health following ACLR. It is important that ACLR patients are educated regarding the risk of PTOA following ACL injury and current options for managing the increased risk of developing a chronic disease. A recent study evaluating how certified athletic trainers perceive and manage the risk of PTOA found that while 97% of healthcare professionals agree that ACL patients should be educated about their increased risk of PTOA following ACLR, only 71% of healthcare professionals actually report explaining this risk to their patients [19]. In a separate study, only 27% of patients with an ACLR reported that a healthcare professional explained risk of PTOA following ACLR, which may explain why most patients believe that ACLR will decrease the risk of PTOA, and only 7% of ACLR patients from the United States believed that developing osteoarthritis was a major healthcare concern [20]. In addition to education, proper movement biomechanics and adequate lower extremity muscle strength should be developed and maintained to decrease the risk of a second traumatic knee injury and chronic aberrant mechanical loading of the ACLR knee. Specifically, quadriceps weakness is associated with increased odds of developing osteoarthritis [21], as well as greater tibiofemoral joint space narrowing [22] and worse self-reported function following ACLR [23]. Clinical efforts should be made to maximize quadriceps strength to achieve inter-limb symmetry and an adequate amount of bilateral strength relative to the individual's body weight [23]. Furthermore, increased disability is often coupled with an increase in non-lean bodyweight following knee injury [24]. Efforts to maintain a healthy bodyweight following ACLR may directly minimize aberrant mechanical loading to the knee [25] and indirectly minimize the potential adverse effects that increased circulating adipocytokines may have on systemic joint inflammation [26]. Finally, it is important that patient education, muscle strengthening, and weight management are managed on a continual basis, and serial assessments of PTOA risk should be conducted even after patients have returned to normal physical activity or active duty.

Acknowledgments

Potential conflicts of interest. B.P. has no relevant conflicts of interest.

  • ©2017 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.

References

  1. ↵
    1. Owens BD,
    2. Mountcastle SB,
    3. Dunn WR, et al.
    Incidence of anterior cruciate ligament injury among active duty U.S. military servicemen and servicewomen. Mil Med. 2007;172(1):90-91.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Sanders TL,
    2. Maradit Kremers H,
    3. Bryan AJ, et al.
    Incidence of anterior cruciate ligament tears and reconstruction: a 21-year population-based study. Am J Sports Med. 2016;44(6):1502-1507.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Gianotti SM,
    2. Marshall SW,
    3. Hume PA,
    4. Bunt L
    Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study. J Sci Med Sport. 2009;12(6):622-627.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Enad JG,
    2. Zehms CT
    Return to full duty after anterior cruciate ligament reconstruction: is the second time more difficult? J Spec Oper Med. 2013;13(1):2-6.
    OpenUrl
  5. ↵
    1. Luc B,
    2. Gribble P,
    3. Pietrosimone B
    Osteoarthritis prevalence following anterior cruciate ligament reconstruction: a systematic review and numbers needed to treat analysis. J Athl Train. 2014;49(6):806-819.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Patzkowski JC,
    2. Rivera JC,
    3. Ficke JR,
    4. Wenke JC
    The changing face of disability in the US Army: the Operation Enduring Freedom and Operation Iraqi Freedom effect. J Am Acad Orthop Surg. 2012;20(Suppl 1):S23-30.
    OpenUrlCrossRefPubMed
  7. ↵
    1. Cameron KL,
    2. Shing TL,
    3. Kardouni JR
    The incidence of post-traumatic osteoarthritis in the knee in active duty military personnel compared to estimates in the general population. Osteoarthritis and Cartilage. 2017;25(Supplement 1):S184-S185.
    OpenUrl
  8. ↵
    1. Murtha AS,
    2. Johnson AE,
    3. Buckwalter JA,
    4. Rivera JC
    Total knee arthroplasty for posttraumatic osteoarthritis in military personnel under age 50. J Orthop. Res. 2017;35:677-681.
    OpenUrl
  9. ↵
    1. Tourville TW,
    2. Johnson RJ,
    3. Slauterbeck JR, et al.
    Assessment of early tibiofemoral joint space width changes after anterior cruciate ligament injury and reconstruction: a matched case-control study. The Am J Sports Med. 2013;41(4):769-778.
    OpenUrl
  10. ↵
    1. Harkey MS,
    2. Luc BA,
    3. Golightly YM, et al.
    Osteoarthritis-related biomarkers following anterior cruciate ligament injury and reconstruction: a systematic review. Osteoarthritis Cartilage. 2015;23(1):1-12.
    OpenUrlCrossRefPubMed
  11. ↵
    1. Li X,
    2. Kuo D,
    3. Theologis A, et al.
    Cartilage in anterior cruciate ligament-reconstructed knees: MR imaging T1{rho} and T2—initial experience with 1-year follow-up. Radiology. 2011;258(2):505-514.
    OpenUrlCrossRefPubMed
    1. Theologis A,
    2. Kuo D,
    3. Cheng J, et al.
    Evaluation of bone bruises and associated cartilage in anterior cruciate ligament-injured and -reconstructed knees using quantitative t(1ρ) magnetic resonance imaging: 1-year cohort study. Arthroscopy. 2011;27(1):65-76.
    OpenUrlCrossRefPubMed
  12. ↵
    1. Theologis AA,
    2. Haughom B,
    3. Liang F, et al.
    Comparison of T1rho relaxation times between ACL-reconstructed knees and contralateral uninjured knees. Knee Surg Sports Traumatol Arthrosc. 2014;22(2):298-307.
    OpenUrlCrossRefPubMed
  13. ↵
    1. Englund M,
    2. Roos EM,
    3. Lohmander LS
    Impact of type of meniscal tear on radiographic and symptomatic knee osteoarthritis: a sixteen-year followup of meniscectomy with matched controls. Arthritis Rheum. 2003;48(8):2178-2187.
    OpenUrlCrossRefPubMed
  14. ↵
    1. Wasserstein D,
    2. Huston LJ,
    3. Nwosu S, et al.
    KOOS pain as a marker for significant knee pain two and six years after primary ACL reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) prospective longitudinal cohort study. Osteoarthritis Cartilage. 2015;23(1):1674-1684.
    OpenUrlCrossRefPubMed
  15. ↵
    1. Purser JL,
    2. Golightly YM,
    3. Feng Q, et al.
    Association of slower walking speed with incident knee osteoarthritis-related outcomes. Arthritis Care Res (Hoboken). 2012;64(7):1028-1035.
    OpenUrl
  16. ↵
    1. Herzog MM,
    2. Driban JB,
    3. Cattano NM, et al.
    Risk of knee osteoarthritis over 24 months in individuals who decrease walking speed during a 12-month period: data from the Osteoarthritis Initiative. J Rheumatol. 2017.
  17. ↵
    1. Pietrosimone B,
    2. Troy Blackburn J,
    3. Harkey MS, et al.
    Walking speed as a potential indicator of cartilage breakdown following anterior cruciate ligament reconstruction. Arthritis Care Res (Hoboken). 2016;68(6):793-800.
    OpenUrl
  18. ↵
    1. Pietrosimone B,
    2. Blackburn JT,
    3. Golightly YM, et al.
    Certified athletic trainers' knowledge and perceptions of posttraumatic osteoarthritis after knee injury. J Ath Train. 2017;52(6):541-559.
    OpenUrl
  19. ↵
    1. Bennell KL,
    2. van Ginckel A,
    3. Kean CO, et al.
    Patient knowledge and beliefs about knee osteoarthritis after anterior cruciate ligament injury and reconstruction. Arthritis Care Res (Hoboken). 2016;68(8):1180-1185.
    OpenUrl
  20. ↵
    1. Oiestad BE,
    2. Juhl CB,
    3. Eitzen I,
    4. Thorlund JB
    Knee extensor muscle weakness is a risk factor for development of knee osteoarthritis. A systematic review and meta-analysis. Osteoarthritis Cartilage. 2015;23(2):171-177.
    OpenUrlCrossRefPubMed
  21. ↵
    1. Tourville TW,
    2. Jarrell KM,
    3. Naud S, et al.
    Relationship between isokinetic strength and tibiofemoral joint space width changes after anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42(2):302-311.
    OpenUrlCrossRefPubMed
  22. ↵
    1. Pietrosimone B,
    2. Lepley AS,
    3. Harkey MS, et al.
    Quadriceps strength predicts self-reported function post-ACL reconstruction. Med Sci Sports Exerc. 2016;48(9):1671-1677.
    OpenUrl
  23. ↵
    1. Myer GD,
    2. Faigenbaum AD,
    3. Foss KB, et al.
    Injury initiates unfavourable weight gain and obesity markers in youth. Br J Sports Med. 2014;48(20):1477-1481.
    OpenUrlAbstract/FREE Full Text
  24. ↵
    1. Messier SP,
    2. Legault C,
    3. Loeser RF, et al.
    Does high weight loss in older adults with knee osteoarthritis affect bone-on-bone joint loads and muscle forces during walking? Osteoarthritis Cartilage. 2011;19(3):272-280.
    OpenUrlCrossRefPubMed
  25. ↵
    1. Richter M,
    2. Trzeciak T,
    3. Rybka JD, et al.
    Correlations between serum adipocytokine concentrations, disease stage, radiological status and total body fat content in the patients with primary knee osteoarthritis. Int Orthop. 2017;41(5):983-989.
    OpenUrl
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Understanding, Detecting, and Managing the Risk of Posttraumatic Osteoarthritis Following Anterior Cruciate Ligament Reconstruction in the Military
Brian Pietrosimone
North Carolina Medical Journal Sep 2017, 78 (5) 327-328; DOI: 10.18043/ncm.78.5.327

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Understanding, Detecting, and Managing the Risk of Posttraumatic Osteoarthritis Following Anterior Cruciate Ligament Reconstruction in the Military
Brian Pietrosimone
North Carolina Medical Journal Sep 2017, 78 (5) 327-328; DOI: 10.18043/ncm.78.5.327
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